Recovering from an ACL injury? Here’s why late-stage rehab is essential in getting you back in the game.
Anterior cruciate ligament (ACL) injuries are one of the most common knee injuries in the active population. There are both surgical and non-surgical management options following ACL injury with a rehabilitation period recommended with both management pathways. The rehabilitation process is designed to run in phases over 9-12 months and begins early after injury.
Throughout rehabilitation, there is a gradual increase in activity and function as you progress from one phase to the next. Each phase has specific goals, with consistent completion of the rehabilitation program being key to a successful recovery.
Do I need to complete late-stage rehab?
Not all of those who suffer an ACL injury return to sport, with only 65% returning to their pre-injury level of activity. Persistent symptoms, repeated ACL injuries and impaired quality of life are also reported during long term follow up. Inadequate rehabilitation has been proposed as a factor in reduced activity levels in those with who have experienced an ACL injury. To ensure a return to full function and activity with the best possible outcome, it is highly beneficial to complete all stages of rehabilitation following ACL injury.
It can be easy to fall off the ‘rehab bandwagon’ for several reasons: loss of motivation, juggling competing commitments, pain free daily activities and return of adequate function. Tracking your progress is a great way to keep motivated, by setting ‘mini challenges’ for yourself throughout what can seem a lengthy rehabilitation process. Each phase has milestones or benchmarks that need to be achieved, to allow you to progress to the next level. Your physiotherapist will use a combination of clinical tests and equipment to assess a selection of criteria, including range of motion and muscle strength. This is valuable information and can determine:
- Your current capacity and status of your rehabilitation
- How your knee compares to your non-injured knee
- How you compare to standard values
- If you have met the current phase milestones and are ready to progress to the next phase of your rehabilitation
What does late-stage rehabilitation involve?
Late-stage rehabilitation is the term given to the rehabilitation phase from 6 months, until return to sport. This is the fun stage of rehabilitation in which your physiotherapist will tailor your program to you and the sport you love. Consultations with your physiotherapist will include discussions about your goals for rehabilitation, specifically what activity or sport you intend to return to. For example, this may be participating in Parkrun each week, cycling on weekends with the family, social tennis with friends, or academy level soccer. Plyometrics are explosive jumping-type exercises and are only introduced in late-stage rehabilitation once the strength foundations have been achieved earlier in the rehabilitation period. One of the main aims of late-stage rehabilitation is prevention of another ACL injury. Rehabilitation and injury prevention programs that include plyometric exercises have been shown to significantly decrease the risk of subsequent ACL injuries by up to 60%.
Late-stage rehabilitation typically involves a specific strength, plyometric and endurance-based program along with running and integration back into your sport or activity. This phase of rehab can be based around your usual sport schedule and in familiar environments. For example, if you are aiming to return to soccer, late-stage rehab could incorporate the following aspects prescribed by your physiotherapist:
- A gym or home-based program targeting lower limb strength and endurance
- Plyometric, jump and landing drills such as box jumps
- Field based conditioning, sprint, and agility drills at your usual soccer fields
- Noncontact ball drills with the team at the regular scheduled training sessions
- Specific warmups incorporating Football Australia’s Injury Prevention Perform+ Program
When can I return to play sport?
The decision and clearance to return to play pivoting and cutting sport, such as soccer or netball, is made in conjunction with your physiotherapist and orthopaedic surgeon. Return to play decisions are made 12-months following surgery at the end of late-stage rehabilitation. Part of this final process includes additional benchmarks and a structured return to play testing protocol performed by your physiotherapist. The return to play testing involves a series of physical knee focused tests, neuromuscular control and landing drills, power measurements and mental readiness questionaries. Those who complete a battery of functional tests prior to a return to sport have a reduced risk of re-injury. Upon return to sport, your physiotherapist will discuss and tailor an ongoing injury prevention program for you. There are a range of sport specific programs, such as the FIFA 11+ and Football Australia Perform+ for soccer and the KNEE program for netball, that have been shown to reduce the risk of injuries when completed two to three times a week.
Completing ACL rehabilitation?
If you are currently completing ACL rehabilitation and would like to track your progress, have lost motivation, or are unsure about whether you are ready to return to sport, book an appointment with your physiotherapist to help you get back in the game with a successful recovery.
Physiologic (Allsports Robina)
Al Attar, W. S. A., Bakhsh, J. M., Khaledi, E. H., Ghulam, H., & Sanders, R. H. (2022). Injury prevention programs that include plyometric exercises reduce the incidence of anterior cruciate ligament injury: a systematic review of cluster randomised trials. Journal of physiotherapy, 68(4), 255–261. https://doi.org/10.1016/j.jphys.2022.09.001
Andrade, R., Pereira, R., van Cingel, R., Staal, J. B., & Espregueira-Mendes, J. (2020). How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II). British journal of sports medicine, 54(9), 512–519. https://doi.org/10.1136/bjsports-2018-100310
Arundale, A. J. H., Bizzini, M., Dix, C., Giordano, A., Kelly, R., Logerstedt, D. S., Mandelbaum, B., Scalzitti, D. A., Silvers-Granelli, H., & Snyder-Mackler, L. (2023). Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. The Journal of orthopaedic and sports physical therapy, 53(1), CPG1–CPG34. https://doi.org/10.2519/jospt.2023.0301
Brinlee, A. W., Dickenson, S. B., Hunter-Giordano, A., & Snyder-Mackler, L. (2022). ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline. Sports health, 14(5), 770–779. https://doi.org/10.1177/19417381211056873
Culvenor, A. G., Girdwood, M. A., Juhl, C. B., Patterson, B. E., Haberfield, M. J., Holm, P. M., Bricca, A., Whittaker, J. L., Roos, E. M., & Crossley, K. M. (2022). Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. British journal of sports medicine, 56(24), 1445–1453. https://doi.org/10.1136/bjsports-2022-105495
Whittaker, J. L., Culvenor, A. G., Juhl, C. B., Berg, B., Bricca, A., Filbay, S. R., Holm, P., Macri, E., Urhausen, A. P., Ardern, C. L., Bruder, A. M., Bullock, G. S., Ezzat, A. M., Girdwood, M., Haberfield, M., Hughes, M., Ingelsrud, L. H., Khan, K. M., Le, C. Y., Losciale, J. M., … Crossley, K. M. (2022). OPTIKNEE 2022: consensus recommendations to optimise knee health after traumatic knee injury to prevent osteoarthritis. British journal of sports medicine, 56(24), 1393–1405. https://doi.org/10.1136/bjsports-2022-106299
Level up your physical and mental well-being - incorporate a Pilates session into your weekly workouts
Looking for a workout that includes fun, fitness and challenges mind and body? Pilates may be your answer.
Shockwave is not a new treatment modality; it has been around since the 1980s where it was initially used to treat kidney stones. Its use in lower limb injuries, is more recent (since the 1990s) where there are several conditions where it has been used effectively and, in some instances, is a legitimate alternative to injections and even surgery.1 A shockwave is a form of an acoustic wave that carries energy and can propagate through tissues causing a biological response.
When referring to this treatment modality, shockwave is more of an abbreviation with the correct term being extracorporeal shockwave therapy. There are a few different types of shockwave therapy that can be used to treat musculoskeletal conditions. The most common for lower limb injuries is extracorporeal radial shockwave therapy; less common is extracorporeal focused shockwave therapy.
The most common musculoskeletal conditions for which shockwave therapy is used are lower limb injuries, particularly plantar fasciitis and Achilles tendinopathy. These conditions are typically treated once per week and the average treatment length is about five sessions but can vary between two and eight sessions. When performed correctly, for the right person and in conjunction with good advice and appropriate exercise or load modification, shockwave therapy has a success rate as high as 90%2 - this is without the need for injections, surgery and consequently no down time.3,4
Other conditions that may be treated with radial shockwave therapy include tendon tenosynovitis, tibialis posterior tendinopathy, muscular trigger points, patella and quadriceps tendinopathy osteoarthritis of the knee/s, gluteal medius tendinopathy or greater trochanter pain syndrome (which includes hip bursitis as part of that syndrome) and medial tibial stress syndrome (shin splints).
How shockwave works
Different mechanisms of action of radial shockwave have been proposed over the years. The production of cavitation bubbles within the tissue is one of the physical mechanisms that has been shown to occur in the tissue5 and may be in impetus to a number of biological processes in the tissue. In terms of the biological process, there have been multiple mechanisms identified including down-regulation of substance P released by C nerve fibres6 which assists with the down regulation of pain. This reduction in substance P would also reduce neurogenic inflammation7 which again will assist with pain relief. Apart from pain relief, shockwave can also induce protein biosynthesis, cell proliferation, neuro and chondroprotection, and destruction of calcium deposits in musculoskeletal structures.8 More recently, shockwave has been shown to increase lubricin expression/production.9 Increased lubricin expression may contribute to pain and symptom relief in musculoskeletal disorders by decreasing erosive wear on tendons and septa.
Muscle injuries in sports do result in player lay-off times and can have an impact on individual and team performance. Extracorporeal shockwave therapy has been used in premier league soccer for a number of years, but the data to date has not been shared outside the clubs. Morgan10 compared injury data by Ekstrand11 and showed that the use of shockwave significantly reduced the mean lay-off times in professional soccer players (reduced by 58% for type 1a injuries, 55% for 2b injuries, and by 21% for 3a injuries). The results suggest that use of shockwave therapy in acute muscular injuries has significant benefits with respect to healing times and returning back to pre-injury status.
New emerging areas in shockwave therapy
There are other emerging areas of shockwave therapy in musculoskeletal therapy. These include treatment of spasticity via induction of transient dysfunction of the nerve condition at the neuromuscular junction12 (similar action to Botox) so watch this space!
Overall, radial shockwave therapy is a proven safe technology and treatment modalities, with very little side effects and no down time (compared with surgery). Shockwave therapy has substantial scientific evidence substantiating its use with these musculoskeletal conditions. If you are unsure if shockwave therapy is right for you, please discuss this with a health professional in a clinic that specialised in the modality. They will be the most equipped to navigating you in deciding if it is the right modality for your condition.
Physiotherapist, Exercise Physiologist, Internationally accredited shockwave therapist, SCDA trainer
B.Sc(Nutrition & Food Science), Grad.Dip.Sci(Exercise Rehabilitation), B.Sc(Physiotherapy)
1 Wuerfel T, Schmitz C, Jokinen LLJ. The Effects of the Exposure of Musculoskeletal Tissue to Extracorporeal Shock Waves. Biomedicines. 2022, 10(5):1084.
2 Wang CJ, Ko JY, Chan YS, Weng LH, Hsu SL. Extracorporeal shockwave for chronic patellar tendinopathy. Am J Sports Med. 2007, 35(6):972-8.
3 Li H, Lv H, Lin T. Comparison of efficacy of eight treatments for plantar fasciitis: A network meta-analysis. J Cell Physiol. 2018, 234(1):860-870.
4 Othman AM, Ragab EM. Endoscopic plantar fasciotomy versus extracorporeal shock wave therapy for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2010, 130(11):1343-7.
5 Csaszar, Nikolaus & Angstman, Nicholas & Milz, Stefan & Sprecher, Christoph & Kobel, Philippe & Farhat, Mohamed & Furia, John & Schmitz, Christoph. (2015). Radial Shock Wave Devices Generate Cavitation. PloS one. 10.
6 Andersson G, Backman LJ, Scott A, Lorentzon R, Forsgren S, Danielson P. Substance P accelerates hypercellularity and angiogenesis in tendon tissue and enhances paratendinitis in response to Achilles tendon overuse in a tendinopathy model. Br J Sports Med. 2011, 45(13):1017-22.
7 Richardson JD, Vasko MR. Cellular mechanisms of neurogenic inflammation. J Pharmacol Exp Ther. 2002, 302(3):839-45.
8 Simplicio CL, Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. J Clin Orthop Trauma. 2020, 11(Suppl 3):S309-S318.
9 Zhang, D., Kearney, C. J., Cheriyan, T., Schmid, T. M., & Spector, M. Extracorporeal shockwave-induced expression of lubricin in tendons and septa. Cell and Tissue Research. 2011, 346(2), 255
10 Morgan, J.P.M., Hamm, M., Schmitz, C. et al. Return to play after treating acute muscle injuries in elite football players with radial extracorporeal shock wave therapy. J Orthop Surg Res, 2021, 16, 708.
11 Ekstrand J, Hägglund M, Waldén M. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med. 2011, 39(6):1226–32.
12 Vidal X, Martí-Fàbregas J, Canet O, Roqué M, Morral A, Tur M, Schmitz C, Sitjà-Rabert M. Efficacy of radial extracorporeal shock wave therapy compared with botulinum toxin type A injection in treatment of lower extremity spasticity in subjects with cerebral palsy: A randomized, controlled, cross-over study. J Rehabil Med. 2020, 30;52(6):jrm00076.